Brain tumor-related epilepsy treatment
Brain Tumor-Related Epilepsy (BTRE) requires a multidisciplinary approach, combining neurosurgery, antiepileptic drugs (AEDs), and oncologic therapies depending on tumor type and patient profile.
Management of seizures in BTRE is complex and with currently available evidence levetiracetam seems the preferred choice. Comparative efficacy RCTs in BTRE are warranted 1) Future studies should consider the use of a standardized method of seizure tracking and incorporating seizure outcomes as a primary endpoint of tumor treatment trials 2) An evolving knowledge of the pathophysiology of BTRE might influence future therapy. Management of withdrawal of ASMs and permission to drive demands thorough diagnostic as well as neurooncological and epileptological expertise 3).
🧠 1. Surgical Treatment
- Goal: Remove the tumor to reduce both mass effect and seizure focus.
- Efficacy: Surgery can lead to seizure freedom in up to 80% of cases with gross total resection.
- Techniques:
- Neuronavigation and intraoperative monitoring (ECoG, awake surgery).
- Supratotal resection may be beneficial in low-grade gliomas.
💊 2. Antiepileptic Drugs (AEDs)
☢️ 3. Oncologic Therapies
- Radiation Therapy:
- Controls tumor growth, may indirectly reduce seizure burden.
- Chemotherapy:
- Temozolomide (especially in glioblastoma) may help reduce seizures over time.
🔄 4. Multimodal Considerations
- Tumor type matters:
- Low-grade gliomas and DNETs are highly epileptogenic.
- Epileptogenic zone:
- May extend beyond visible tumor → requires mapping.
- Teamwork:
- Requires coordination between neuro-oncology, neurosurgery, and epileptology teams.
🧩 5. Emerging and Adjunct Therapies
- Neurostimulation:
- VNS, RNS for drug-resistant BTRE.
- Ketogenic diet:
- Occasionally used in refractory epilepsy.
- AI and precision medicine:
- Tools under development for seizure prediction and individualized therapy.
🧠 Summary Table
| Treatment | Goal | Notes |
|---|---|---|
| Surgery | Tumor + seizure control | Highest chance of seizure freedom |
| AEDs | Symptom control | Levetiracetam is first-line |
| Radiotherapy/Chemo | Tumor control | May improve seizure control long-term |
| Multidisciplinary approach | Optimize outcomes | Epileptologist + neurosurgeon + oncologist |
Treatment for Brain tumor-related epilepsy presents unique challenges, mainly related to burdens of polytherapy, debated necessity of anti‑epileptic prophylaxis, and overall impact on the QoL. There are no established protocols to guide the use of these medications at every step of disease progression. Treatment strategies aimed at the tumor, that is surgical procedures, radio‑ and chemotherapy appear to influence seizure control. Conversely, some antiepileptic drugs have also shown antitumor properties 4)
Patients with brain tumor-associated seizures need treatment with antiepileptic drugs (AEDs) to prevent a recurrence, whereas strong clinical data exists to discourage routine prophylaxis in patients who have not had seizures. The newer AEDs, such as levetiracetam, lamotrigine, lacosamide, topiramate, or pregabalin, are preferable for various reasons, primarily related to the side-effect profile and limited interactions with other drugs. If seizures persist despite the initiation of an appropriate monotherapy (in up to 30-40% of cases), additional anticonvulsants may be necessary. Early surgical intervention improves seizure outcomes in individuals with medically refractory epilepsy, especially in patients with a single lesion that is epileptogenic. Data for this review article were compiled by searching for scholarly articles using the following keywords: a brain tumor, epilepsy, seizure, tumor-related epilepsy, central nervous system, epidemiology, review, clinical trial, and surgery. Articles were screened for relevance by title and abstract and selected for review and inclusion based on significant contribution to the topics discussed 5).